1. Employee volunteers to participate in the program and to adhere to applicable policies, guidelines, and procedures. 

Agency concurs with employee participation and agrees to adhere to applicable policies, guidelines and procedures.

2. Participation in the program will last commencing on

and ending on .

3. Employee's official duty station tour of duty will be from to (e.g., 8:30 A.M to 5:00 P.M.

including a one-half hour non-paid lunch period) on the following days: .

Employee's telework tour of duty will be from to on the following days:

.

Fixed schedule in accordance with local guidance and/or collective bargaining agreement.

Flexitime in accordance with local guidance and/or collective bargaining agreement.

AWS in accordance with local guidance and/or collective bargaining agreement.

TELEWORK AGREEMENT

DLA FORM 1865, JUL 2004 Page 1 of 3

6. These dates/times may be modified as needed to meet mission requirements as required or approved by the

supervisor in accordance with local guidance and/or collective bargaining agreement.

7. All pay, leave, and travel entitlements will be based on the employee's official duty station.

8. Employee's timekeeper will have a copy of the employee's telework schedule and will record the time and

attendance as if performing official duties at the official duty station.

9. If leave is taken, employee will notify the supervisor following the local guidance and/or collective bargaining

agreement.

10. Employee will continue to work in pay status while working at the alternative work site. If employee works overtime

that has been approved in advance, he/she will be compensated in accordance with applicable law, regulations, or

other pay guidance. The employee will not work in excess of his/her prescheduled tour of duty (including overtime,

compensatory time, religious time, or credit hours) unless he or she receives permission from his or her supervisor. 

By signing this form, employee agrees that failing to obtain proper approval for overtime work may result in his/her

removal from the telework program or other appropriate action.

11. If employee uses Government equipment, employee will use and protect the Government equipment in

accordance with Agency policy and procedures. Government-owned equipment will be serviced and maintained by the

government. If an employee provides his/her own equipment he/she is responsible for purchasing and installing any

software, servicing it and maintaining it. Use of personally owned computer equipment to connect to the DLA network

is approved if appropriate security software is installed and security procedures are followed to avoid risk of intrusion or

impact to the DLA environment.

12. DLA retains the right to inspect the home work site, by appointment only, to ensure proper maintenance of

Government-owned property and safety standards, provided management has reasonable cause to believe that a

hazardous work environment exists. 

FormFlow (DLA)

Grade and Job Series Supervisor 

Employee Job Title 

4. Employee's Official Duty Station address: 5. Approved Alternative Worksite Address: 

Phone Number: 

Number of Days per Week Telework is Authorized: 12345
13. DLA will not be liable for damages to an employee's personal or real property during the course of performance of

official duties or while using DLA equipment in the employee's residence, except to the extent DLA is held liable by the

Federal Tort Claims Act or claims arising under the Military Personnel and Civilian Employees Claims Act.

14. DLA will not be responsible for operating, maintenance, or any other costs (e.g., utilities) whatsoever associated

with the use of the employee's residence. The employee does not relinquish any entitlement to reimbursement for

authorized expenses incurred while conducting business for the government, as provided by statute and implementing

regulations.

15. Employee is covered under the Federal Employee's Compensation Act if injured in the course of actually

performing official duties at the official alternate work site. Any accident or injury occurring at the alternate duty station

must be brought to the immediate attention of the supervisor. Because an employment-related accident sustained by a

telework employee will occur outside of the premises of the official duty station, the supervisor must investigate all

reports as soon as practical following notification.

16. The employee is required to designate one area in the home as the official work or office area that is suitable for

the performance of official government business. The government's potential exposure to liability is restricted to this

official work or office area for purposes of telework.

17. Employee will meet with the supervisor to receive assignments and to review completed work as necessary or

appropriate.

18. All assignments will be completed according to the work procedures, guidelines and standards stated in the

employee's performance plan.

19. Employees will apply approved safeguards to protect Government/DLA records from unauthorized disclosure or

damage and will comply with Privacy Act requirements set forth in the Privacy Act of 1974, PL 93-679, codified at

Section 552a, Title 5 USC.

20. Employees shall manage all files, records, papers, or machine-readable material and other documentary materials,

regardless of physical form or characteristics, made or received during telework in accordance with DLAI 5015.1, DLA

Records Management Procedures and Records Schedule.

21. No classified documents (hard copy or electronic) may be taken to, or created at, an employee's alternative work

site. For Official Use Only and sensitive non-classified data may be taken to alternative work sites if necessary

precautions are taken to protect the data, consistent with DoD regulations.

22. Telework will be terminated if it adversely affects the performance of the employee.

23. Supervisors have the authority to call any employee in to the official duty station for mission needs at any time. 

Call back outside the telework hours/dates are handled in accordance with established policy and/or collective

bargaining agreement.

24. After appropriate notice to the supervisor, the employee may cancel the telework arrangement.

25. The employee continues to be covered the the DLA standards of conduct while working at the alternative work site.

26. The employee acknowledges that telework is not a substitute for dependent care.

27. Employee acknowledges that he/she has read and understands the Privacy Act Statement on page 3 of this form.

DLA FORM 1865, JUL 2004 Page 2 of 3

SUPERVISOR'S SIGNATURE DATE 

EMPLOYEE'S SIGNATURE DATE 

If either the supervisor or employee cancels this agreement, fill in the information on page 3.
If either the supervisor or employee cancels this agreement, fill in the information below.

EMPLOYEE'S SIGNATURE 

DLA FORM 1865, JUL 2004 Page 3 of 3

Cancellation Date: 

Reason(s) for cancellation: 

Cancellation was:

Employee-initiated Supervisor-initiated

SUPERVISOR'S SIGNATURE DATE 

DATE 

PRIVACY ACT STATEMENT

AUTHORITY:

PRINCIPAL PURPOSE(S):

ROUTINE USES:

DISCLOSURE:

DLA PRIVACY ACT SYSTEM NOTICE S330.10 APPLIES

Public Law 106-346, Sec. 359, Transportation Appropriations Act, 2001 (Telecommuting).

Information is collected to register individuals as participants in the DLA alternate workplace program; to manage and document the duties of

participants; and to fund, evaluate and report on program activity. The records may be used by Information Technology offices for determining

equipment and software needs; for ensuring appropriate system safeguards are in place, and for managing technological risks and

vulnerabilities.

Information may be disclosed for any of the Routine Uses published by DLA and posted at 

http://www.defenselink.mil/privacy/notices/dla/dla_preamble.html.

Disclosure is voluntary. However, failure to provide the requested information may result in our inability to include you as a participant in the

alternate workplace program.